The right and wrong ways to dismiss patients

Gary LeRoy, MD, a primary care physician in Dayton, Ohio, recalls an incident at East Dayton Health Center when a patient with mental health issues became belligerent and tried to grab a front-desk employee through the window.

“That person was immediately given a verbal notification that he was being discharged from the office,” LeRoy says. “We had our office manager draw up the letter immediately.”

Although this kind of incident is the exception, not the norm, it does illustrate that sometimes, practices need to dismiss a patient. Most often, patients pose problems like non-adherence to treatment plans or failure to show up for appointments and need to be managed on a regular basis.

Terminating a patient relationship is “not a first-resort issue because the doctor-patient relationship is really paramount,” says Carrie Horwitch, MD, a Seattle-area internist and chairwoman of the American College of Physicians committee on ethics, professionalism and human rights.

“It’s very uncommon for doctors to summarily dismiss folks because they’re an annoyance,” LeRoy agrees. “It’s our responsibility to ferret out whether there is something there that can be fixed.”

Some Cases Merit Dismissal

While physicians should be circumspect about “firing” patients in most types of cases, they are well within their bounds to dismiss patients who are violent, verbally abusive or use their trusted doctor-patient relationship to feed drug addictions.

When a patient becomes violent or physically threatening, Horwitch says, they need to be dismissed. “The cases I am familiar with, where a dismissal became necessary, was where a patient came in with a gun to a clinic and threatened somebody,” she says. “Then it’s a safety issue not only to clinicians and staff but to other patients.” LeRoy cites another type of situation that often warrants dismissal: when patients with drug addictions forge or alter a prescription, or “physician shop” to get prescriptions.

“That violates our trusted relationship, where I cannot provide you medical care,” he says. “If they’re at the emergency room for an overdose of a controlled substance that I didn’t give them, [the next time I see them] I ask, ‘Where did you get this?’ That’s grounds for dismissal,” at least potentially, judged case by case.

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